Background/Objectives The primary objective of this study was to describe the time to first acute-care use (e.g., emergency department use without hospitalization or rehospitalization)for older adults who discharged to home after receiving post-acute care in skilled nursing facilities (SNFs). The secondary objective was to identify predictors of patients' first acute-care use. Design Retrospective cohort study using administrative claims data. Setting SNFs providing post-acute care in North and South Carolina (N=1,474). Participants A cohort of Medicare beneficiaries aged 65 years and older (N=55,980) who were hospitalized, then transferred to a SNF for post-acute care, and subsequently discharged home (January 1, 2010, to August 31, 2011). Measurements Medicare institutional claims data (Part A and Part B) and Medicare enrollment data were used; facility-level variables were obtained from CMS Nursing Home Compare. Survival from SNF discharge to first acute-care use was explored. Cox proportional hazards regression models were used to describe patient, home care and nursing facility-level predictors. Results After SNF-to-home discharge, 22.1% of older adults had an episode of acute-care use within 30 days, including 7.25% with an ED visit without hospitalization and 14.8% with a rehospitalization; 37.5 % of older adults had their first acute-care usewithin 90 days. Male gender, dual eligibility status, higher Charlson co-morbidity score, certain primary diagnoses at the index hospitalization (neoplasms and respiratory disease), and care in SNFs with for-profit ownership or fewer licensed practical nurses hours per patient day were associated with higher risk for acute-care use. Conclusion Medicare patients have a high use of acute-care services after discharge from SNFs, and several factors associated with acute-care use are potentially modifiable. Findings suggest the need for interventions to support patients as they transition from SNFs to home.
BackgroundLittle is known about the sustainability of behavioral change interventions in long-term care (LTC). Following a cluster randomized trial of an intervention to improve staff communication (CONNECT), we conducted focus groups of direct care staff and managers to elicit their perceptions of factors that enhance or reduce sustainability in the LTC setting. The overall aim was to generate hypotheses about how to sustain complex interventions in LTC.MethodsIn eight facilities, we conducted 15 focus groups with 83 staff who had participated in at least one intervention session. Where possible, separate groups were conducted with direct care staff and managers. An interview guide probed for staff perceptions of intervention salience and sustainability. Framework analysis of coded transcripts was used to distill insights about sustainability related to intervention features, organizational context, and external supports.ResultsStaff described important factors for intervention sustainability that are particularly challenging in LTC. Because of the tremendous diversity in staff roles and education level, interventions should balance complexity and simplicity, use a variety of delivery methods and venues (e.g., group and individual sessions, role-play/storytelling), and be inclusive of many work positions. Intervention customizability and flexibility was particularly prized in this unpredictable and resource-strapped environment. Contextual features noted to be important include addressing the frequent lack of trust between direct care staff and managers and ensuring that direct care staff directly observe manager participation and support for the program. External supports suggested to be useful for sustainability include formalization of changes into facility routines, using “train the trainer” approaches and refresher sessions. High staff turnover is common in LTC, and providing materials for new staff orientation was reported to be important for sustainability.ConclusionsWhen designing or implementing complex behavior change interventions in LTC, consideration of these particularly salient intervention features, contextual factors, and external supports identified by staff may enhance sustainability.Trial registrationClinicalTrial.gov, NCT00636675
This study provides evidence of lower quality postdischarge care for Medicare beneficiaries in rural settings. As readmission penalties expand, hospitals serving rural beneficiaries may be disproportionately affected. This suggests a need for policies that increase follow-up care in rural settings.
Objectives:The purpose of this study is to determine the prevalence of methamphetamine-related diagnoses seen in the psychiatric emergency department (ED) of a large urban hospital, which serves an area with a known methamphetamine epidemic. This study also examines the characteristics and ED interventions of psychiatric patients with and without methamphetamine-related diagnoses. Methods:The records of 904 patients admitted to the psychiatric ED of the largest urban hospital in Hawaii between March and May 2002 were reviewed. Diagnoses were made according to the Diagnostic and Statistical Manual of Mental Disorders IV. Patients were classified as having a methamphetaminerelated diagnosis if they were diagnosed with methamphetamine intoxication, dependency, abuse, withdrawal, methamphetamine-induced mood disorder or psychotic disorder. Results:One hundred sixty-six patients (18%) were diagnosed with a methamphetamine-related diagnosis. Patients with methamphetamine-related diagnoses were more likely to be male (70% vs. 57%), nonCaucasian (75% vs. 57%), and presented with suicidality (47% vs. 32%) and agitation (48% vs. 30%) more often than non-methamphetaminerelated diagnosis patients. Poly-drug use (14% vs. 3%) and dual diagnosis (37% vs. 17%) were more common among patients with methamphetaminerelated diagnoses. Patients with methamphetamine-related diagnoses were treated with sedating medications more frequently (37% vs. 25%), stayed longer in the ED (median 225 vs. 193 min), and were more likely to be admitted to the hospital (53% vs. 40%) than non-methamphetaminerelated diagnoses patients. Conclusions:Psychiatric ED patients with methamphetaminerelated diagnoses present more acutely and use more hospital resources.
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